Provider Demographics
NPI:1992012587
Name:ELLINGSWORTH, LANI LAURI
Entity Type:Individual
Prefix:MS
First Name:LANI
Middle Name:LAURI
Last Name:ELLINGSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5692 E BUCKINGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-7605
Mailing Address - Country:US
Mailing Address - Phone:559-681-8074
Mailing Address - Fax:
Practice Address - Street 1:611 E BELMONT AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-1502
Practice Address - Country:US
Practice Address - Phone:559-237-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)